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The Beacon Community Program goals include building and strengthening a health information technology infrastructure; improving health outcomes, care quality, and cost efficiencies; and

spearheading innovations to achieve better health and health care.

Beacon Community of the Inland Northwest

Overview of Beacon Community of the Inland NorthwestBetter diabetes care coordination and management are at the heart of the Beacon Communityof the Inland Northwest (BCIN). Patients with diabetes need preventive health services in order to stay healthy and reduce instances of complications related to the disease. For example, 3 in10 diabetic patients do not receive the recommended number of blood sugar tests within a year,and more than 1 in 4 adults with diabetes do not receive an eye exam; both of which are part of the standard of care that can contribute to positive health outcomes. The BCIN is facing thisproblem head on. It represents 14 counties in eastern Washington, north central Washington,and northern Idaho, with large rural and traditionally medically underserved populations.

BCIN is building on and strengthening an existing quality improvement and technologyinfrastructure to spread care coordination services to a large population. It is expanding asuccessful Centers of Occupational Health & Education (COHE) initiative that deploys carecoordinators to improve provider-patient communication and improve patient self-managementand adapting this model to address diabetes care in the region. It is also strengthening andexpanding the Inland Northwest Health Services (INHS) health information network, whichconnects 38 hospitals and health care facilities in eastern Washington and western Idaho,

allowing thousands of providers to securely access patient information using wired and wirelesstechnologies. It includes more than 3.5 million electronic health records (EHRs).

Goal of the ProgramThe BCIN aims to increase care coordination for patients with diabetes in rural areas andexpand the existing health information exchange network to provide a higher level of connectivity throughout the region. Specifically, the BCIN is working to achieve three objectives:• • •

Reduce emergency and inpatient care for diabetes and its complicationsIncrease receipt of diabetes preventive health servicesImprove access to diabetes preventive health services information by public health agencies

Using Health Information Technology to Make a DifferenceOne aspect of successful preventive care coordination is the exchange and meaningful use of electronic health information between providers responsible for different aspects of care. TheBCIN is enhancing the data that are collected and the way data are shared to ensure BCINpatients with diabetes get the services they need. For example:• Many complications from diabetes can be prevented when appropriate primary care is

received in a routine and timely manner. When patients don’t have complications, they don’tneed to visit the emergency room (ER) or go to a hospital. The BCIN is collecting data fromthe EHRs maintained by participating hospitals to track care received by Beacon patients in

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ERs and hospitals. It hopes to see less use of these expensive services because of coordinated care and preventive services for patients with diabetes. As a result, patients arehealthier.

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The BCIN is connecting more providers—and more kinds of providers—to the existing INHShealth information exchange, gathering data on diabetes care, and helping providers givepreventive health care services to their patients with diabetes.How well providers deliver these services is fed back to them in the form of qualitydashboards and provider scorecards. It is anticipated that doctors will use this information tofill gaps in care; improved quality of care will lead to improved health for patients.Better data—and better access to data—help public health agencies develop better interventions to promote population health. The INHS health information network isconnected to public health reporting systems so that BCIN-related aggregate data can besent to and used by public health agencies.

The BCIN is also deploying disease management and electronic clinical decision support toolsto help health care providers improve follow-up and management of patients with chronicdisease with an initial focus on diabetes. Other information technology tools include qualitydashboards—graphic arrays of information that highlight providers’ performance in specificareas of quality—and provider report cards. Lessons learned from BCIN’s experience inimplementing community-based and provider-level performance monitoring and reporting willhelp other communities seeking to establish similar initiatives.

A Team ApproachIn addition to INHS, other BCIN partners include Community Choice, the Washington StateDepartment of Health, the Washington Academy of Family Physicians, the Critical AccessHospital Network, SAIC, and the North Central Washington Health Collaborative. Twenty-fivehospitals, 18 health centers, and more than 3,200 doctors, as well as pharmacies and long-termcare agenci

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Bes across vast geographic regions, have indicated interest in collaborating on the

CIN. The BCIN also works with the Washington & Idaho Regional Extension Center to helptors select, install, and use EHRs.

Improvements for Patients and the Community The BCIN intends to improve the health of patients with diabetes and reduce regional healthcare costs due to diabetes-related complications through a variety of health informationtechnology solutions, such as EHR upgrades and interfaces, to enable data sharing betweenproviders.

The BCIN expects that these health information technology solutions will help improve thehealth of patients with diabetes by:• •

Enacting more routine and timely care for diabetes patients to help prevent complicationsReducing regional health care costs due to diabetes-related complicationsImproving coordination of care between health care providers and their patients withdiabetes.